2.0 Analysis 2.1 Preparations for Sea The skipper was new to the SCOTIA GOLD and this may have been why he overlooked several things before determining that the vessel was ready for sea. The hatches on deck were not properly secured and, as fishing operations were not intended during the transit voyage, operation of the deck wash-down system was unnecessary. There was no notice that the deck wash-down hose leading overboard had disconnected nor were steps taken to shut down the system or redirect the flow to prevent seawater being pumped onto the deck, thus contributing to flooding of the vessel through the unsecured deck hatches. Also, the cover plates over the propeller shaft/drain well in the fish hold were improperly placed, which lead to the blockage of the bilge suction line by crushed ice and the inability of the main bilge pump to drain the fish hold and engine-room. The vessel was not inspected prior to departure nor were periodic rounds made of the vessel during transit. No deck watch system was in place which could have served to alert the crew of the conditions or circumstances that allowed water ingress. This permitted the ingress to go unnoticed for several hours. The failure to maintain watertight integrity of compartments has been identified as a causal factor in a number of marine occurrences; the problem is predominantly in the fishing industry. The Board, concerned about shipboard practices that compromise watertight/weathertight integrity of vessels, made a number of recommendations to the Minister of Transport to address this issue. In response to the recommendations, the Minister of Transport instituted measures that included: intensifying the examination of masters, mates and engineers on matters related to watertight/weathertight integrity (TSB Recommendation M93-01); issuing/re-issuing several Ship Safety Bulletins (SSB), the most recent being 08/98 and 16/96--the latter addressing stability and seaworthiness issues (TSB Recommendations M92-04, M93-01); and issuing a special edition of the SSB 02/93 to reach several thousand fishing vessel owners, listing titles of all SSBs since 1977, to address effectiveness of SSB distribution practices (TSB Recommendation M93-02). Despite these initiatives by TC, the failure to maintain watertight/weathertight integrity of the vessel, particularly in the fishing industry, continues. 2.2 Acquisition of SAR Pumps by the Canadian Coast Guard The CCG decision to replace the previously SAR-approved Briggs Stratton/Ohler pump with the much less expensive Honda unit appears to have been initiated primarily as a cost-cutting measure. It has been reported by some in the CCG that the Honda pump unit is easier to start and maintain. This could be the case when the units are new, carefully handled, used only for fresh water purposes and started on a relatively stable platform. However, differences of opinion exist within the ranks of CCG SAR personnel as to the practical attributes of the Honda pump unit versus the SAR-approved type. Given the manufacturer's strict warnings and specified limitations on the use of the pump, it seems that the Honda equipment has been adopted without the formal pre-acquisition/technical approval procedures normally required in the selection of such essential marine emergency equipment. 2.3 Suitability of Honda Pump for its Intended Use and its Compatibility with the Modified Container In the CCG's selection of the Honda pump unit, adequate consideration was not given to the design of the container in which the new pump would be stored and to potential problems associated with dissimilar metal parts within the pump. The use of an aluminium pump casing with steel impeller parts in the corrosive environment of seawater will cause galvanic action resulting in accelerated corrosive attack of the aluminium, besides the normal oxidization of ferrous metal parts. The container is one component of an approved Briggs Stratton/Ohler customized package and as such is designed to resist the forces normally associated with air drops and ship-to-ship handling of that particular assembly. The decision taken to make a pump unit from one manufacturer fit into the container made especially for a different pump unit compromised the protection afforded by the container. A fracture discovered in the helicopter-supplied Honda pump's suction flange was established as the cause of pump failure. Although it is unknown precisely when the fracture in the suction flange occurred, the pump must have been damaged sometime after leaving the maintenance depot, while on board or being lowered to the water by the helicopter, or during its recovery by the SCOTIA GOLD. Given that the flanged suction fitting was hard against the inside of the container, an impact load at this point of contact would cause a shearing force at the flange corner. The crack in the flange was found to have propagated from this point. The incompatibility of the pump unit and container was such that the pump suffered damage during its normal handling between the depot and being hauled aboard the SCOTIA GOLD. It is thus unlikely that the assembly would have survived an air drop--the alternative method of delivery. Unlike the Briggs Stratton/Ohler portable de-watering pump assemblies, which are ruggedly constructed for marine use, the Honda replacements do not have special features found in such SAR-approved assemblies, including: A gasoline motor fitted with a protective device to prevent the pull-start cord from jamming the recoil starting mechanism. A pump casing and internal impeller parts made from the same metal alloy to resist electrolytic corrosion in seawater. The motor/pump unit with its carrying frame custom-designed to fit its drum container, allowing for appropriate protective clearance to resist equipment damage upon impact. 2.4 Transport Canada Marine Safety Surveyors' Requirements Where vessels take on water, a portable de-watering pump can be a vital piece of safety equipment. However, Transport Canada (TC) Marine Safety regulations for small fishing vessels do not require the carriage of such a pump. The portable Honda de-watering pump carried on board the SCOTIA GOLD was additional equipment to that required by TC regulations. Once on board, the pump's general purpose use, lack of frequent maintenance and inability to operate safely in a seawater environment resulted, over time, in the aluminium and steel pump parts becoming so severely corroded that the unit failed to operate when needed in this emergency. TC Marine Safety does not approve pumps of any particular make or model, including those required by regulations in terms of number, type and rating. It has not been determined how many fishing vessels and other craft are required by TC Marine Safety in the Maritimes region to carry portable de-watering pumps. However, the unreliability, over time, of portable pump units not designed for marine operations poses a serious threat to the safety of such ships and to their crews in emergencies. 3.0 Conclusions 3.1 Findings Good seamanship practices were not followed and the skipper did not ensure that the deck hatches were properly secured, and water on deck entered the fish hold, then passed through the non-watertight bulkhead to the engine-room. The crew was unaware that the deck wash-down hose leading overboard had become disconnected, causing seawater to be pumped onto the deck, thus contributing to flooding of the vessel through the unsecured hatches. The absence of a deck watch system allowed the ingress of water to go unnoticed for several hours. Displaced portable cover plates over the drain well in the fish hold permitted ice slurry to enter the drain well and block the suction pipe to the main bilge pump, rendering the pump ineffective. Both the SCOTIA GOLD and the Canadian Coast Guard (CCG) helicopter-supplied portable Honda de-watering pumps' starting mechanisms jammed. When started, both portable Honda de-watering units failed to pump. The ship's pump failed due to severe internal corrosion, and the CCG unit's failure was due to a broken suction flange. The Briggs Stratton/Ohler portable de-watering pump supplied by the Canadian Coast Guard Cutter (CCGC) CUMELLA, and used successfully to pump out the SCOTIA GOLD, is a specially customized pump unit/container assembly approved for Search and Rescue (SAR) use by the United States Coast Guard (USCG) and Canada's Department of National Defence (DND). The portable Honda de-watering pump units lack fundamental safety features characteristic of a SAR-approved assembly, such as: means to prevent the pull-start cord from jamming; pump components designed to avoid electrolytic corrosion in seawater; and design-fit clearances between the pump unit and container wall customized so as to resist equipment damage upon impact from an air drop or during normal conditions of emergency deployment. Honda Canada declares that its portable gasoline driven de-watering pumps are intended to be used as economical drainage pumps for most general-purpose water pumping applications and warns that, to avoid pump corrosion, they should never be used to pump seawater. ]Honda does not manufacture a pump assembly specifically suited to a salt water environment. At the time of the occurrence, the CCG had almost completed its program to replace the Briggs Stratton series of SAR-approved de-watering pump units with the Honda models. The portable Honda de-watering pump costs significantly less than the Briggs Stratton unit, and this factor was taken into account during the CCG selection process. There is no formal approval process of portable SAR de-watering pumps by a recognized marine authority. Officials of the CCG SAR Branch support the ongoing use of Honda portable pumps; however, differences of opinion prevail within the ranks of CCG personnel as to the pumps' attributes in comparison with those of SAR-approved assemblies. One of the two CCG service depots visited did not maintain Honda portable de-watering pumps in its inventory, as the units were considered to be prone to salt water corrosion and unsuitable for marine use. The maintenance and inventory records of SAR de-watering pumps at two CCG service depots were found to be inadequate, incomplete, and in some cases, non-existent. Transport Canada (TC) Marine Safety does not approve portable de-watering pumps or ship's pumps, although regulations dictate the number, type and rating of pumps to be installed. Fishing vessels are not required by regulation to carry a portable de-watering pump. However, at the time of re-certification of fishing vessels, and duly considering the vessel's age, structure, nature of intended voyages and all aspects of safety, Marine Safety surveyors may require the carriage of a portable de-watering pump over and above all other regulatory requirements. The SCOTIA GOLD carried a portable Honda pump unit on board as additional equipment to that required by TC Marine Safety regulations for small fishing vessels. 3.2 Causes The SCOTIA GOLD took on water through poorly secured deck hatches. Displaced cover plates in the fish hold permitted ice slurry to enter the shaft tunnel/drain well, block the suction line to the main bilge pump and render the pump ineffective. As a result of previously undetected corrosion or damage, the portable de-watering pumps failed to operate. The portable pumps were not designed for the type of marine operation in which they were employed. 4.0 Safety Action 4.1 Action Taken 4.1.1 Pump Maintenance and Packaging In April 1997 the CCG was apprised of the lack of reliability of a particular model of de-watering pump used by the SAR units, as the pumps apparently degraded when used in sea water and were damaged when dropped from a SAR helicopter, causing mechanical failure. In response, the Coast Guard initiated an internal investigation to find out why this particular pump model was almost exclusively used by the SAR units, and why the pump delivered on the fishing vessel SCOTIA GOLD malfunctioned. As a result, a decision was made that the CCG will not purchase any further Honda pumps for SAR duties. Further, the CCG has begun to standardize SAR pumps with equipment that is better suited to the marine environment. The CCG issued a memorandum to its regions to remind every CCG ship and CG base and SAR station to follow the scheduled maintenance according to the manufacturer's operator's manual, to rinse pumps and equipment with fresh water after use in sea water and to test pumps and equipment on a monthly basis on vessels and at CCG bases. The memorandum recommended that the Yarmouth-based CG helicopter carry a drum container--adequately packed for this purpose and capable of withstanding an air drop--similar to what DND aircraft carry, and also recommended that CCG ships, CCG bases and SAR stations be made aware of the danger of pump malfunction resulting from strong impact, and take appropriate measures regarding drum container packing. TSB also apprised TC, via the Marine Safety Advisory No. 1/97, of the need to ensure proper maintenance and operation of various portable de-watering pumps now in service. TCMS issued Ship Safety Bulletin No. 4/98 alerting owners to the dangers of using inappropriate equipment and to the necessity of maintaining all equipment in good working condition.